Thank you Nurses!



This will be the first blog entry about how much I appreciate nurses at the opioid treatment programs I work with.

I’ve been remiss. Some of the best people I’ve ever met have been nurses at opioid treatment programs. Nearly without exception, they have been bright, caring, and compassionate.

At my OTP, we are temporarily short-staffed with nurses, so the stress they deal with is even more evident than usual. New nurses are being hired, so help is on the horizon, but right now, things are tense. Our nurses try to dose patients as quickly as possible without making any dosing errors.

Being a nurse at an opioid treatment program isn’t an easy job. I’ve overheard one imprudent program manager, several years ago, make an unfortunate comment that being a nurse at an OTP was easy, and that “anyone” could do it. He had no medical background, so he can be forgiven for his lack of knowledge.

Not every RN or LPN can manage to do this job well; it takes a special heart.

First of all, the state of North Carolina disagrees that “anyone” can do the job of a nurse at an OTP. They insist you have a nursing degree, so there’s that.

Secondly, medical professionals of all types have jobs where mistakes can be deadly. The ordinary human errors that cause problems in other work environments can kill in our line of work. That’s a special kind of stress. We accept that stress as part of the price of working as a medical professional, and we also accept that other people can never understand what that feels like.

Over a decade ago, I knew a nurse who made a dosing error by mis-reading the physician’s induction order for a patient on methadone. She gave a somewhat higher dose than was ordered by the physician on day two and day three. The patient died on day three. Of course the family was devastated, and a lawsuit ensued, settling for an undisclosed amount. But that nurse will never be the same. She left the OTP and I don’t know if she’s still working as a nurse or not. But that illustrates what a nursing error at an opioid treatment program can mean.

Out of all we do at OTPs, the most critical moment of care happens when the nurse hands over the patient’s daily dose of medication. The patient must be quickly assessed for impairment by the nurse, and the correct dose of medication given. This must be done perfectly, day after day, patient after patient. Any mistakes made at this point can undo the rest of treatment.

Any time perfection is expected of you at your job…that’s stress. And just like nurses in all medical settings, they are also being asked to work faster and faster, to be ever more efficient.

I’m not saying the counselors don’t also have high-stress jobs. Lord knows they do. But their errors don’t have the same ability to kill someone.

Thirdly, the amount of documentation and record-keeping demanded from nurses at the opioid treatment program is mind-blowing. These documents are intermittently inspected by the state’s department of health and human services, by the DEA, by the state opioid treatment authority, by CARF, etc. Someone is always looking over their shoulder, because they are working with strong opioid medications.

I’ve seen many nurses who couldn’t cut it in the OTP. It’s fast-paced and exacting, and often they deal with difficult people. Sometimes patients get angry at the restrictions of the opioid treatment program, many of which are mandated by state and federal organizations. Patients often direct their anger at the nurses. I’m often amazed at their ability not to take these outbursts personally. I’m afraid I might harbor resentment, but they seem to start over every day.

This is not a glamorous field of nursing. On the totem pole of medical specialties, addiction medicine and especially opioid treatment programs are the part of the pole that’s underground. When these dedicated professionals tell their friends and families about the work they are doing, they are sometimes chided for not doing something more mainstream. Or their family thinks their job consists of “shooting up them addicts with methamphetamine,” as one nurse told me.

Of course, we in the addiction treatment field know these nursing professionals are likely helping more people at the opioid treatment program than they would at any office or hospital setting.

It takes strong character to do a difficult job well, especially when you don’t get a lot of praise from nurse peers who know little about this niche area of medicine

So today I am honoring the nurses who work at opioid treatment programs. Thank you for the work you do. You are appreciated.



17 responses to this post.

  1. Posted by kathleen ray on February 15, 2016 at 2:56 pm

    Thank you for the thank you note for nurses. Though I am not working in the addiction field at present time, having worked in ED at local hospital for many, many years, I can understand and appreciate the conditions that addiction nurses must deal with. I can vividly recall the facial expressions/reactions from my fellow nurses when I informed them that I planned to work in addictions nursing. It is the stigma of addiction even among the medical profession that continues to be an obstacle to overcome. Having attended numerous addiction themed conferences and proud to say that i now have the CARN certification, I am currently seeking per diem position in methadone clinic or similar setting. And thank you for all that you do,


  2. Posted by Andrew angelos on February 15, 2016 at 4:18 pm

    What is the longest time a patient can get take home meds at your clinic. Is the take home schedule different for methadone and suboxone.


    • Since it is an OTP, both methadone and buprenorphine patients must follow the same take home schedule, according to our state laws. As you know, the federal regulations dropped the time in treatment requirement several years ago. But we must abide by our state’s laws too.
      Having said that, we do have a SOTA who will grant exceptions relatively early for buprenorphine patients who are doing very well, because this medication is safer than methadone. If we have a patient who’s been dosing daily for a month, getting counseling, has a stable home and work life, and a couple of negative drug screens, we can ask for level 3 and it’s usually granted.
      I think our highest take home level among our methadone patients right now is 2 weeks (level 6), and the highest for buprenorphine is one month.


  3. I love your topic. Nurses saved my life in 1980, when the ill-informed Docs dropped me from 80mg. over 8yrs. to 0. They talked me through the panic and gave me hope. Little did I know that my symptoms would last a year but that’s probably good.
    Today, I am married to a RN, who brings her own recovery to her lectures, as well as, to our ambulatory detox protocol. She was awarded the Outstanding Clinician, by Addiction Professional, for her 29 yrs. of work training every single graduating classl of nurses from Mt. San Jacinto Junior College. Her safety protocols, also, have become a model for Optum and we were awarded the Impact Award for our training to them.
    She, now, has her sights set on undoing the oxymoron called “non-medical detox” that is part of Calif’s, licensing. I have, yet, to find a facility, so licensed, that didn’t use controlled substances, lay housemanagers to dispense (and in some cases prescribe). Either, you do detox, and have achieved the necessary medical safety protocol and staff, or you are hiding under this very dangerous, useless licensure. If an individual is sick enough to need detox, they are sick enough to need physicians, nurses and safety protocols, at screening to insure that prospective patients meet ASAM criteria for patient placement. “Detox programs” are popping up all over the state and insurance companies are feeding them by allowing payments. Too many of these patients have, already, died. We need more addiction trained nurses to treat the increasing acuity of today and tomorrow’s patients and SOCIAL MODEL DETOX is not it!!!.


  4. As a nurse working in an OTP, I thank you! I seldom feel appreciated by management. I do believe that people think it’s an easy job. I thoroughly enjoy your blog.


  5. Posted by TJ Miley, LPN on February 15, 2016 at 10:44 pm

    Thank you Dr B.
    It’s all good in OTP.


  6. Posted by Kevin on February 17, 2016 at 7:03 am

    I have to say because sometimes I arrive 2 or 3 hrs before the doors open just to be the first one in and hopefully the first 10 or so out, the nurses are usually 1 of the first ones to arrive at these clinics sometimes an hr or so before they even open. They have to get up at 230 of 3am for work, I imagine go to bed at 7 or so at night. I can’t imagine having to go to bed at that time. So from one of millions of patients I thank you for getting up so early to deal with me, I am one of the few that tries to show you the respect you deserve because it’s not always your fault us patients can’t have everything our way!!!


  7. Posted by Christy LPN on February 19, 2016 at 12:46 pm

    Thank You! Such a honor you appreciate nurses at OTP’s. Our work is so rewarding. The people we serve are amazing individuals and I count as all joy to have had the opportunity to do so.


  8. Posted by Kim G on February 25, 2016 at 2:56 am

    Great post! Wish all doctors had the compassion that you do and were as passionate about saving lives as you are and not just any life but the lives of those that many see as hopeless. You are extraordinary for these 2 things alone but then you add respect and concern for the staff that you work with, making each feel appreciated, you are the very definition of what a doctor should be. THANK YOU! and thank you to the nurses and all the staff that share this compassion.


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